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Show Rising Incidence of Antibiotic-Resistant Pneumonia-causing Bacteria Data on the incidence of infections due to antibiotic-resistant Streptococcus pneumoniae are not available in Utah because only outbreaks are reportable according to the current Utah Communicable Disease Rule. In 1995, the Council for State and Territorial Epidemiologists and the Centers for Disease Control and Prevention (CDC) recommended that states require reporting of antibiotic-resistant Streptococcus pneumoniae. Currently 19 states comply, and a revision of the Utah Communicable Disease Rule has been proposed that would make infections with antibiotic-resistant Streptococcus pneumoniae reportable. The Surveillance Network Database-USA, a national database (unpublished, MRL Pharmaceutical Services, 6/1/98) of results from selected laboratories, reports decreasing incidence of penicillin-susceptible strains of Streptococcus pneumoniae from 87.3% in 1992 to 56.9% in 1997. The Pacific Mountain region, which includes Utah, reports only 50.4% penicillin-susceptible strains (213 isolates from all sources) for the first 6 months of 1997. Primary Children's Medical Center, a tertiary care pediatric hospital in Salt Lake City, Utah, reports 76% penicillin-susceptible strains in 1993, and only 59% in 1997 (unpublished, Primary Children's Medical Center microbiology laboratory). Traditional defenses against drug-resistance have been development of new antibiotics, targeted surveillance, and isolation. However, with Streptococcus pneumoniae, the resistance is arising in the ambulatory setting and subsequently becoming a problem in acute care settings (McGowan and Tenover, 1997), so isolation as a strategy is less useful. Recent strategies have been targeted at the outpatient setting for more rational prescribing of antibiotics for the treatment of childhood infections, often viral. With the rising incidence of drug-resistant bacteria, prevention of infection is more important than ever. The CDC (Drug-Resistant Streptococcus pneumoniae Working Group) recommends a strategy of targeted vaccination programs to regions with high levels of antibiotic-resistant organisms (facilitated by improved detection using the latest penicillin-resistance screening techniques by laboratories and mandatory reporting of infections with drug resistant bacteria). Vaccination should also be targeted to persons at high risk for infection (possibly including children > 2 years of age in child care centers). The Working Group also promotes judicious use of antimicrobial drugs (avoiding broad spectrum agents, using proper dose and duration, and following established recommtableendations for chemoprophylaxis) (CDC, February 1996). Vaccines-Effective, and Underutilized Studies have shown effectiveness of the pneumococcal pneumonia vaccine in immunocompetent persons >65 years to be 75%. The vaccine is extremely safe, with minimal local side effects and rare systemic reactions (CDC, April 1997). Medicare Part B began reimbursing for the pneumococcal vaccine in 1981. The vaccine is indicated once for all persons after age 65, at least 5 years after a previous administration if given before 65 years of age. Revaccination is currently not recommended except for those at highest risk for infection (patients with asplenia, for example) and those who are most likely to have a rapid decline in protective antibody levels because of underlying conditions (such as nephrotic syndrome, renal failure or renal transplant patients) (CDC, April 1997). Studies are ongoing which suggest efficacy of the vaccine declines over 5-10 years (Shapiro, et al., 1991). Influenza vaccine is recommended yearly by the Advisory Committee on Immunization Practices for all persons >65 years of age (contraindications include only a history of anaphylaxis to eggs or the vaccine). Significant side-effects are rare. When the vaccine is matched to the epidemic viral strains that year, and when vaccination rates of high risk persons are high, vaccination is currently the most effective measure for reducing the morbidity and mortality of influenza (CDC, May 1996). Influenza vaccination became a covered benefit under Medicare Part B in 1993. Fedson, et al. (1993) reported that influenza vaccination in a case-control study of all non-institutionalized adults aged > 45 years (cases=5,036, each matched with 3 controls, 70-75% were > 65 years) in Manitoba, Canada in 1982-83, and 1985-86, prevented 32-39% of hospital admissions with pneumonia and influenza. They estimated 43-65% effectiveness in preventing deaths from influenza-associated conditions. Multiple studies have also demonstrated that these vaccinations are cost-effective. Fieback and Beckett (1994) report a cost-effectiveness analysis for influenza vaccine which showed a cost of $145 per year of life gained. Nichol et al. (1994) performed a serial cohort study of 75,000 persons > 65 years of age enrolled in a health 58 |
